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Objective The aim of this study was to evaluate (a) the surgical outcomes of pectineal ligamenthysteropexy (PLH) for uterine prolapse by laparotomy and (b) the feasibility and safety of the procedure by laparoscopic route.

Methods This is a retrospective consecutive case series of women who underwent PLH from January 1998 to December 2011. The prolapsed uterus was suspended with polyester tape to pectineal ligament on either side through a Cherney incision or laparoscopically at 3 urban and 3 rural hospitals in India.

Results In 194 women who underwent PLH (176 open and 18 laparoscopic), there were no intraoperative complications. The mean follow-up was 6.5 years (range, 0.5–12 years) for open method and 1 year (range, 0.5–2 years) for laparoscopic approach. There were 46 births in 40 women after the procedure including 32 vaginal and 14 cesarean deliveries. Overall, 10 women (5.1%) had uterine prolapse recurrence; 7 of these occurred after vaginal delivery. One woman had tape erosion into the bladder because of pelvic tuberculosis. At follow-up, 12 women developed cystocele, and 7 women developed portio vaginalis elongation. There were no postoperative enteroceles. Overall reoperation rate was 14.9%. Laparoscopic PLH had minimal morbidity with no recurrence over 2 years.

Conclusions Open PLH for uterine prolapse may be safely performed and gives durable support to the prolapsed uterus with low recurrence risk.

Pectineal ligamenthysteropexy is a safe technique that gives durable support to the prolapsed uterus with low recurrence rates.

This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.

Uterine prolapse is commonly treated with vaginal hysterectomy and vaginal vault suspension. However, vaginal hysterectomy does not address the inherent weakness of support at level 11 evident by the common occurrence of vault prolapse after vaginal hysterectomy for uterine prolapse.2 Hysterectomy is known to compromise ovarian blood supply and induce earlier ovarian failure, exposing the woman to cardiovascular and skeletal morbidity.3

Among uterine-conserving procedures, the earliest, Manchester operation or its modification, corrects prolapse of only a limited degree by shortening of the weakened supports. The other option is to create a new level 1 support by suspending the uterus to a robust anchoring structure in the pelvis such as anterior longitudinal ligament over the sacral promontory or sacrospinous ligament. Suspension to these anchoring points may incur risk for injury to adjacent vessels and nerves with morbid outcomes.4–6 Mesh procedures such as posterior intravaginal slingplasty have been reported to have a discouraging incidence of erosion, infection, and dyspareunia.7 Thus, although uterine preservation is a viable option for the surgical management of uterine prolapse, the evidence on safety and efficacy of such conservative procedures is currently lacking.8

The simplicity, safety, and effectiveness of pectineal ligament suspension of the prolapsed uterus (henceforth pectineal ligamenthysteropexy [PLH]) were first reported in 19939 by open method by the first author and later peer reviewed.10,11 The same anchoring structure was used for suspension of prolapsed vaginal vault with excellent results.12,13 This article reports the collective experience of the same author and 7 other gynecologic surgeons who had different levels of surgical experience with this procedure to evaluate its long-term effectiveness. At 1 center, the procedure was done laparoscopically in the last 2 years of the study period to evaluate its feasibility and safety.

METHODS

This is a retrospective consecutive case series of women who underwent PLH from January 1998 to December 2011. Pectineal ligamenthysteropexy was offered to all premenopausal women presenting with grade 2 or 3 uterine prolapse with cervix at or outside the introitus, with or without vaginal prolapse. Women with cervical elongation without concomitant uterine prolapse and those requiring hysterectomy were excluded from the study. After informed consent, the procedures were done at 3 urban and 3 rural hospitals. Authors R.S., M.S., and S.B. performed the procedures independently after an experience of 3 years. The other authors had surgical experience of 10 to 20 years. Author M.B. performed all procedures by laparoscopic approach in his institution. All women were given perioperative antibiotic prophylaxis with cefazolin 2 g. Women with ulceration on the ectocervix had preoperative vaginal packs soaked with povidone iodine to repose the uterus until healing occurred. The study was approved by the KEM Hospital Ethics Committee based on previous publications.9,10,12

The operative technique of the open method has been described earlier.9 With the patient in semilithotomy position, Cherney incision was used for wider exposure of the retropubic space. The loose peritoneum overlying the cervix was incised at the level of the internal os. The needle swaged to the Mersilene tape (Ethicon Division of Johnson & Johnson Ltd, Aurangabad, India) measuring 30 × 0.5 cm was passed through the anterior wall of the uterus 1.5 cm above the level of the internal os, to include approximately 1.5 to 2 cm length and full depth of uterine tissue short of the uterine cavity (Fig. 1). The tape was pulled till its midpoint to make both arms equal in length. Prolene (Ethicon Division of Johnson & Johnson Ltd) 1–0 sutures on either side firmly fixed the tape to the uterus (Fig. 2).

The ends of the tape were drawn into the retropubic space by a long hemostat passed subperitoneally from the retropubic space, just below the lateral end of the round ligament, toward the lateral edge of the peritoneal incision over the uterus (Fig. 3). The peritoneum overlying the tape anchored to the cervix was closed. The pectineal ligament was exposed by dissecting overlying fibrofatty tissue and coagulating any vessels encountered. The lateral end of the tape was passed through an adequate thickness of the pectineal ligament on either side as laterally as possible (Fig. 4). The 2 ends of the tape were then drawn taut to maximally elevate the uterus and were anchored to the pectineal ligaments using 3 firm knots of the tape. Additional 1–0 gauge Prolene sutures were passed through the pectineal ligament and tied around the Mersilene knots (Fig. 5).

If a simultaneous Burch colposuspension was planned, sutures passed through the paravaginal fascia and vaginal wall at the level of the bladder neck were anchored to the pectineal ligaments anteromedial to the knots of the tape. An enterocele when present was repaired at this stage by Moschcowitz or Halban sutures. After closing the abdomen, amputation of an elongated cervix, anterior colporrhaphy, or posterior colpoperineorrhaphy was done when indicated.

The laparoscopic procedure was accomplished with 1 main port and 3 ancillary ports.

One port was placed 2 to 3 cm from the anterior superior iliac spine in the spinoumbilical line on the left side, and the second port was placed 8 to 10 cm from the first port in the midclavicular line. The third port was placed 2 to 3 cm from the anterior superior iliac spine in the spinoumbilical line on the right side. The entire length of pectineal ligament on each side was exposed by opening the overlying peritoneum. Vessels overlying the ligament were carefully desiccated to avoid weakening of the fibers of the ligament.

The tape was inserted in the peritoneal cavity with 1 needle first and then the other with Reich technique. In this, the 5-mm port cannula was removed, and a needle holder was passed through it to grasp the suture 2 cm from the needle. Then the needle holder was inserted through the 5-mm incision into the peritoneal cavity drawing the needle with it. Following this, the cannula was slid over the needle holder into the port site incision. While a uterine manipulator steadied the uterus, the needle was passed through the bared anterior uterine wall, and tape was fixed with Prolene sutures similar to the open technique. Using a long atraumatic grasping forceps, the lateral ends of the tape were brought in to the retropubic space and anchored to the pectineal ligament on each side as in the open technique. The peritoneal incisions were sutured with 1–0 Vicryl (Ethicon Division of Johnson & Johnson Ltd) sutures.

The Foley catheter inserted preoperatively was removed on the seventh postoperative day if Burch colposuspension was done. In all other cases, the catheter was removed after 24 hours. Before discharge, an ultrasonography was done to assess bladder capacity and postvoid residual urine.

Women were followed up after 1 and 6 months and then annually. At each visit, women were asked for vaginal bulging, lower urinary tract symptoms, dyspareunia, and rectal symptoms. Detailed pelvic examination was done to assess the descent of the cervix and vaginal walls in supine and squatting positions with Valsalva maneuver. For the sake of uniformity across centers from the beginning of the study, the Baden-Walker halfway system was used to assess the descent of uterus and vaginal walls.

Data were collected by chart review of patient records at the respective participating centers. The primary outcome measure was recurrence of uterine prolapse beyond first degree, that is, the descent of the cervix into the lower half of the vagina. Secondary outcome measures were presence of prolapse in other compartments, cervical elongation, dyspareunia, erosion of tape, and lower urinary tract symptoms. Results are presented using means and standard deviation or range for continuous variables and with counts and percentages for categorical variables.

RESULTS

From January 1998 to December 2011, of 315 premenopausal women presenting with uterine prolapse, 194 underwent PLH after informed consent. The others (121 women) declined conservative surgery and preferred to undergo vaginal hysterectomy. The mean operating time was 90 minutes (range, 60–160 minutes) for open and 120 minutes (range, 80-180 minutes) for laparoscopic procedures. There were no intraoperative complications such as injury to uterine femoral or obturator vessels, or urinary bladder. There was no instance of hemorrhage or blood transfusion requirements in any of the women.

Table 1 describes the preoperative clinical profile of the patients. In addition to vaginal bulging, 24 women with cystocele complained of incomplete emptying of bladder, 20 had stress urinary incontinence, 48 had dyspareunia, and 15 had blood-stained discharge from ulceration.

The mean duration of follow-up was 6.5 years (median, 6 years) ranging from 2 to 14 years for the open approach. Forty-four women (25%) were followed up for 6 months to 2 years, 45 (25.5%) for 2 to 5 years, 60 (34%) for 5 to 10 years, and 27 (15.5%) for more than 10 years. Eighteen women were lost to follow-up after 2 years from surgery and 6 after 5 years with overall 24 women (12%) loss to follow-up rate. Women who underwent laparoscopic PLH were all followed up for a period of 6 months to 2 years.

Among 176 women in the open PLH, 84 had concurrent tubectomy, and 10 women had prior tubectomy. Of the 82 women who were trying to conceive, there were 46 deliveries among 40 women over the follow-up period. Of these, 14 had cesarean deliveries for obstetric indications. No woman reported pregnancy loss or any other complications during pregnancy. However, we do not have data on specific pregnancy-related complications.

Table 3 summarizes adverse outcomes. Ten women had recurrence of uterine prolapse of third degree in the follow-up period (overall failure rate of 5.1%). Of these, 7 recurred after vaginal delivery and were treated by vaginal hysterectomy, wherein it was noted that the tape had avulsed from the uterus in all of them. There were no recurrences after cesarean deliveries.

Two women had recurrence within 2 months after the procedure. As they declined repeat uterine conservation surgery, they underwent vaginal hysterectomy with vault suspension.

Twelve women developed new grade 2 or greater cystocele after PLH by open method that required anterior colporrhaphy. There was no enterocele or rectocele in any patient.

There were no recurrences in the 2-year period after laparoscopic PLH.

One year after having undergone open PLH, a woman came with recurrent uterine prolapse of third degree with hematuria, urinary urgency, and frequency. At cystoscopy, the Mersilene tape was found to have eroded into the bladder. After excision of the tape, hysterectomy was done, and biopsy of caseous deposits in the pelvis confirmed the diagnosis of genital tuberculosis.

Cervical elongation up to the introitus without uterine prolapse was observed in 7 women 2 to 3 years after PLH. These women did not have cervical elongation at the time of their PLH. They were treated with cervical amputation and reconstruction. Tables 4 and 5 summarize the failure rate and overall reoperation rates after PLH, respectively.

Four women whose prolapse had been corrected by PLH were subjected to abdominal hysterectomy for symptomatic uterine leiomyomas. These women did not have leiomyomas at the time of PLH. No difficulty was encountered during bladder dissection or securing uterine pedicles. The tape was divided from the uterus on each side, and the lateral segments of the tape were left retroperitoneally.

All women who had dyspareunia or urinary complaints before surgery were relieved of their symptoms at follow-up. None of the women had new urinary symptoms such as frequency, urgency, or incomplete voiding, except the 12 women who had cystoceles. All women had adequate bladder capacity, and none had elevated postvoid residual urine on ultrasonography at discharge.

DISCUSSION

We have shown in the present report the safety and long-term durability of PLH by open method in 176 women up to 14 years with recurrence in only 10 women (5.6%). Of these 10 recurrences, 7 occurred after vaginal childbirth and 3 in nonpregnant women. All recurrences that occurred in pregnant women were after vaginal birth and none during pregnancy or after cesarean delivery. In the 2 women with recurrence unrelated to pregnancy, the recurrence could be attributed to poor quality of uterine tissues or inadequate depth of the tape in the uterus.

Pectineal ligament is a robust anchoring structure for the uterus, and access or anchorage to it does not incur risk for injury to the ureter, rectosigmoid, pudendal and sacral vessels, and nerves. While passing the needle through the uterine wall, one should be mindful of the proximity of uterine vessels on either side. The obturator vessels are located deep into the pelvis and away from the pectineal ligament. They are close by during bladder dissection off the vaginal wall at Burch colposuspension when done concurrently. Because the Mersilene tape lies entirely outside the peritoneal cavity, there is no possibility of adhesions with the bowel or omentum. The only case of erosion of the tape into the bladder occurred in a woman who had developed extensive genital tuberculosis. The ends of the tape are attached as laterally as possible on the pectineal ligaments to ensure space for bladder to fill. Ultrasonographic examination indicates that the bladder distends above and lateral to the 2 arms of the tape (Fig. 6).

Unlike Prolene mesh, polyester tape is an inherently strong type 3 synthetic graft that does not require fibroblast proliferation for it to be integrated into adjoining tissue. There are no studies to show that either polyester or polypropylene is the superior of the 2 or to recommend any one over another on the basis of physical characteristics or surgical outcomes.14

A grade 1 cystocele is automatically corrected by elevation of the prolapsed uterus by this suspension operation alone.15,16 If a woman has grade 2 cystocele with or without urinary stress incontinence, concomitant Burch colposuspension can be performed. For a grade 3 cystocele, anterior colporrhaphy is best done after the suspension operation for any cystocele that remains uncorrected. During this repair, care must be taken to avoid any traction on the cervix because this may avulse the tape from the uterus. When a woman has associated cervical portio vaginalis elongation, cervical amputation with reconstruction is performed after the uterine suspension. The low (6.8%) long-term occurrence of prolapse in other compartments after PLH, based on objective evaluation, suggests that good level 1 support prevents recurrence of prolapse at levels 2 and 3.

When a patient who has undergone PLH requires cesarean delivery, the lower segment is incised above and adequately away from the tape attachment. Hysterectomy later in life for benign uterine and/or adnexal pathology requires little modification. After opening the leaves of the broad ligament, the tape is divided at its attachment to the uterus on either side. The tape does not interfere with any of the subsequent steps of hysterectomy. The entire width of the vault can be attached to the end of the Mersilene tape on 1 side using 1–0 guage Prolene sutures to prevent vault prolapse. This changes the axis of the upper vagina to 1 side. The end result is identical to that of pectineal ligament suspension of prolapsed vaginal vault.13

Our results of PLH compare favorably with those of other uterine conserving procedures for uterine prolapse. The Manchester operation or its modification is associated with 20% recurrence, decreased fertility, and 50% pregnancy wastage.11,17 Cervical stenosis, which is known to occur in 11% of women after surgery, can lead to hematometra besides making it difficult to obtain tissue from the cervix and endometrium for cytology and histology.11

Sacrospinous hysteropexy is associated with 7% to 17% recurrence of uterine prolapse, and 40% develop stage 2 anterior compartment prolapse.11 Known complications of a sacrospinous fixation of prolapsed uterus or vaginal vault are hemorrhage; cystitis; perforation of the bladder, rectum, or small bowel; rectovaginal fistula; postoperative pain of the gluteal region; and nerve injury.6

Sacrocervicopexy by open or laparoscopic approach is associated with recurrence rates from 0% to 22%, depending on the type of mesh used.11 However, the sample sizes were small or the duration of follow-up of these individual studies were short.11 The largest study reported 140 cases of laparoscopic sacral hysteropexy with 4% apical recurrence, 4% serious complications, and 25% new anterior vaginal wall prolapse beyond the hymeneal ring with a 22% loss to follow-up.18 Whether done by laparotomy or laparoscopic approach, life-threatening hemorrhage from median sacral vessels is a small but real risk.4 Mesh adhesion with the bowel may necessitate reoperation.18 Hysterectomy done after sacrocervicopexy could be technically difficult because of adhesions.

One of the limitations of this study is that prolapse assessments were not done with the Pelvic Organ Prolapse Quantification system. The Baden-Walker halfway system was used even before the Pelvic Organ Prolapse Quantification system got established in clinical practice in India, and for sake of uniformity across centers, it was continued. Second, there was a 12% (24 women) loss to follow-up. Assuming that all of them had recurrence of uterine prolapse, the failure rate would be 17.5%. However, until their last visit, they had no uterine descent. We are not aware if they had recurrence after last follow-up. Finally, as with all retrospective studies, our study also has an inherent informational bias.

The strengths of this study are its sample size and long duration of follow-up. In addition, the study has the largest data on pregnancy and its outcomes after conservative surgery for uterine prolapse. Because the study was done by surgeons of varying experience, it has high external validity.

CONCLUSIONS

Pectineal ligamenthysteropexy for uterine prolapse by open method can be safely performed by a gynecologic surgeon and gives durable support to the prolapsed uterus with low recurrence rates. Cesarean delivery is recommended in women who conceive after hysteropexy. Laparoscopic PLH is safe with good short-term results.

ACKNOWLEDGMENTS

The authors gratefully acknowledge the women in the study. The authors also thank Dr M.Y. Bapaye, Director of the Department of Surgery, KEM Hospital, Pune, India, for his valuable guidance, as well as Drs Vidya and Ravindra Sathe, Dr Santosh Kirloskar, Dr Nirupama Sakhadeo, Dr Hiraji Pawar, and Dr Ojaswini Tamboli for their surgical contribution. In addition, the help of Dr Meera Joshi with the photographs is gratefully acknowledged.